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Devoted GIVEBACK Ohio (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Devoted GIVEBACK Ohio (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Devoted GIVEBACK Ohio (HMO) in 2025, please refer to our full plan details page.
Devoted GIVEBACK Ohio (HMO) is a HMO plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in Northern Ohio. This plan received an overall rating of 4.5 out of 5 stars in 2025.
It's important to know that Devoted GIVEBACK Ohio (HMO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Devoted GIVEBACK Ohio (HMO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Devoted GIVEBACK Ohio (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $174.70. You must continue to pay paying your reduced Part B Premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has a $590.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $6750.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The Devoted GIVEBACK Ohio (HMO) plan has a $590 deductible for prescription drugs. After the deductible is met, you will pay either a copay or coinsurance depending on the drug tier and pharmacy. For example, you will pay a $3 copay for preferred generic drugs at a standard or mail order pharmacy. For standard generic, preferred brand, and non-preferred drugs, you pay 25% coinsurance. Once your total drug costs reach $2000, you enter the catastrophic coverage phase, where you pay nothing for Medicare Part D covered drugs.
Additional Benefits
The Devoted GIVEBACK Ohio (HMO) plan provides comprehensive coverage for inpatient and outpatient hospital services, with varying copays. Emergency and primary care services also have coverage, with no copay for primary care physician visits. The plan includes benefits for hearing, vision, and dental services, with copays for exams and specific services. Additional benefits include coverage for ambulance, home health, and skilled nursing facility services, with specific copays and coinsurance for certain services. The plan also covers diagnostic and radiological services, medical equipment, and home infusion services. However, services such as transportation, orthodontics, and many "Other Services" are not covered by this plan.
Inpatient Hospital See details
Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered. For Inpatient Hospital-Acute, you will pay a $450 copay for days 1-5, and no copay for days 6-90. For Inpatient Hospital Psychiatric, you will pay a $450 copay for days 1-5, and no copay for days 6-90. Additional Days for Inpatient Hospital-Acute are covered with no copay, but Non-Medicare-covered Stay for Inpatient Hospital-Acute, Upgrades for Inpatient Hospital-Acute, Additional Days for Inpatient Hospital Psychiatric, and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services, including all outpatient hospital services, are covered by the Devoted GIVEBACK Ohio (HMO) plan. Outpatient hospital services have a copay between $0 and $550, and observation services have a copay of $450. Ambulatory Surgical Center (ASC) Services have no copay, and outpatient substance abuse services have a copay of $45 for both individual and group sessions.
Partial Hospitalization See details
Partial Hospitalization is covered by the Devoted GIVEBACK Ohio (HMO) plan, with a $70 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Devoted GIVEBACK Ohio (HMO) plan. Ground ambulance services have a copay of $0-$350, while air ambulance services have a 20% coinsurance. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the Devoted GIVEBACK Ohio (HMO) plan. Emergency Services have a $125 copay, and Urgently Needed Services have a copay between $0 and $55. Worldwide Emergency Transportation has a $350 copay and 20% coinsurance, and both Worldwide Emergency Coverage and Worldwide Urgent Coverage have a $125 copay.
Primary Care See details
The Devoted GIVEBACK Ohio (HMO) plan covers primary care services, including physician services, with no copay. Chiropractic services have a $20 copay, but routine care is not covered. Occupational therapy has a $45 copay, and specialist services have a $45 copay. Mental health specialty services and psychiatric services have a minimum copay of $45 for individual and group sessions. Other health care professional services have a copay between $0 and $45. Physical therapy and speech-language pathology services have a copay between $45 and $65. Additional telehealth benefits have a copay between $0 and $45. Opioid treatment program services have a $45 copay.
Preventive Services See details
The Devoted GIVEBACK Ohio (HMO) plan covers preventive services, including Medicare-covered services, annual physical exams, health education, weight management programs, alternative therapies, nutritional/dietary benefits, fitness benefits, home and bathroom safety devices and modifications, kidney disease education services, glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a welcome visit. However, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge in-home medication reconciliation, re-admission prevention, wigs for hair loss related to chemotherapy, therapeutic massage, adult day health services, home-based palliative care, in-home support services, support for caregivers of enrollees, additional sessions of smoking and tobacco cessation counseling, enhanced disease management, telemonitoring services, remote access technologies, and counseling services are not covered.
Hearing Services See details
Hearing services include routine hearing exams with a $10 copay for one visit per year and fitting/evaluation for hearing aids with no copay. Prescription hearing aids are covered with a copay between $0 and $299 for up to two hearing aids per year, but hearing aids for the inner ear, outer ear, and over the ear are not covered. OTC hearing aids are not covered.
Vision Services See details
The Devoted GIVEBACK Ohio (HMO) plan covers vision services, including eye exams with a $10 copay, and eyewear with a combined maximum benefit of $300 every year. Contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades are also covered.
Dental Services See details
The Devoted GIVEBACK Ohio (HMO) plan covers Medicare Dental Services with a $45 copay, and other dental services including oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery. Orthodontics, maxillofacial prosthetics, and implant services are not covered. There is a maximum benefit of $300 per year for other dental services.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. For Medicare Part B Insulin Drugs, there is a $35 copay and 20% coinsurance. Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the Devoted GIVEBACK Ohio (HMO) plan. The coinsurance for dialysis services is between 20% and 20%.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with a 20-30% coinsurance and no copay, Prosthetic Devices with 0-20% coinsurance and no copay, and Medical Supplies with a 20% coinsurance and no copay. Durable Medical Equipment for use outside the home, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by the Devoted GIVEBACK Ohio (HMO) plan, including all diagnostic services, Diagnostic Procedures/Tests, and Lab Services. Diagnostic Procedures/Tests have a copay of $0 to $150, while Lab Services and Outpatient X-Ray Services have no copay, and Diagnostic Radiological Services have a copay of up to $300. Therapeutic Radiological Services have a coinsurance of at least 20%.
Home Health Services See details
Home Health Services are covered by the Devoted GIVEBACK Ohio (HMO) plan with no copay and no coinsurance, but prior authorization is required. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but none of the listed services are covered. The plan does not specify the copay or coinsurance for these services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered under the Devoted GIVEBACK Ohio (HMO) plan, with a $0 copay for days 1-20, and a $214 copay for days 21-100. Additional days beyond Medicare-covered for SNF and Non-Medicare-covered stays for SNF are not covered.
Other Services See details
The Devoted GIVEBACK Ohio (HMO) plan's "Other Services" benefit is not covered, as all sub-services including Acupuncture, Over-the-Counter (OTC) Items, Meal Benefit, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services, are not covered.
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Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
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